Sanctioning Iranians’ health

The recent interim deal reached between the P5+1 powers and Iran over the country’s nuclear energy programme has become the latest political football for President Barack Obama and Congressional leaders, many of whom seem aghast at even the minimal relief in economic sanctions it promises. The suffering of the Iranian people, far from being a point of concern, has been upheld by Senators John McCain and Chuck Schumer as evidence of the sanctions’ success in “bringing Iran to the negotiating table”.

The cumulative effect of the policy is often proudly referred to, among politicians of all stripes, as “crippling”. Though one wouldn’t know it from the sterile coverage of the sanctions by US news outlets, nowhere can the crippling effect be more clearly observed than in the daily lives of average Iranians.

Iran’s economy has been plunged into a recession, with GDP contracting by 5.4 percent over the past year. Rising unemployment coupled with an inflation rate of 40 percent (the real figure is reportedly double this) has eaten away at the country’s middle class, with 40 percent of Iranian families now living under the poverty line. In a recent Gallup poll, 85 percent of Iranians reported that their livelihoods have been hurt “a great deal” or “somewhat” by the sanctions.

As is usually the case in economic crises, the healthcare sector has been especially hard-hit.

‘The price is worth it’

Before the sanctions reached their full impact over the past two years, the Iranian healthcare system was long considered one of the most advanced in the Middle East, with health standards among the highest in the developing world. Beginning in the 1980s, the country implemented a nationwide primary care network, based around community health workers that brought health care to 23 million rural dwellers, many of whom had never before seen a doctor, while reducing rural infant mortality by 75 percent.

In recent decades, Iran also realised “the largest and fastest drop in fertility ever recorded” through, among other measures, the dissemination of free contraception to the population. Many of these birth control pills were manufactured by the country’s domestic pharmaceutical industry, which was nurtured over a period of decades and had made the country self-sufficient for 90-97 percent of its medicinal needs.

Following the tightening of the US-led sanctions over the past two years, that industry, like many others, has faced severe shortages of the raw materials necessary for manufacture. Imports of newer, more advanced medicines from US and European drug manufacturers decreased 30 percent in 2012. Shortages of modern anesthetics are forcing surgeons to turn to outmoded, riskier drugs while operating, while hemophilia medicines were at one point reduced to a third of their previous availability.

The Obama administration has long claimed that the sanctions are not intended to hurt the civilian population, citing provisions that exempt humanitarian items, such as medical supplies and agricultural goods, as evidence of a “smart sanctions” policy as opposed to one of collective punishment. In July 2013, it expanded a list of exempted medical products that companies can export without prior approval under a standing authorisation.

In reality, these pronouncements amount to little more than public relations gestures that function to cloak the sanctions with a veneer of humanitarian concern while they inflict enormous damage on the lives of ordinary Iranians. Illustrating the toothless nature of the exemptions, the administration’s list of permitted medical supplies is largely restricted to rudimentary medical devices, such as tongue depressors and medical shoe covers that Iran could easily make itself.

Based on interviews with US Treasury officials, the International Crisis Group observed that the notable absence of any pharmaceuticals on the list is due to concerns that these so-called “dual-use” products could theoretically be converted to military use.

This disturbingly echoes the rationale invoked during the era of UN sanctions against Iraq less than two decades ago, in which Washington and London’s routine blocking of what they similarly dubbed dual-use items, such as childhood vaccines and water treatment equipment under the Oil for Food programme, led to the deaths of up to 500,000 children under 5 by 2003. Then-Secretary of State Madeleine Albright’s infamous proclamation that these deaths were a “price…worth” paying for US goals has been reprised in Rep Brad Sherman’s (D-CA) open (albeit refreshingly honest) call to “hurt the Iranian people”.

More fundamentally, the alleged humanitarian exemptions have been rendered meaningless by a sanctions regime that has functioned – as intended – as a blunt instrument against Iranian economic activity.

As highlighted in a report released last year by the Wilson Center, the blacklisting of Iran’s Central Bank and “draconian” penalties for sanctions violations have made private banks exceedingly reluctant to finance any imports, medical or otherwise. A lack of hard currency has made Iran increasingly dependent on a barter system to obtain potentially poorer quality drugs from China and India, while for the newest medicines still under patent, there is no alternative source. Prohibitions on shipping have further choked off vital trade routes.

In an implicit acknowledgement that the sanctions regime has hindered the import of humanitarian supplies, the P5+1 pledged, as part of the recent nuclear deal, to “facilitate” the import of exempted humanitarian items, such as medicines and medical devices through the creation of a separate financial channel to handle these transactions.

Sanctioning helath care

However, the Obama administration has as yet provided no specifics on how it would implement this provision and address the root causes within the financial and shipping systems inhibiting the import of humanitarian items. Indeed, since the deal, the administration has stepped up its crackdown on alleged sanctions violators, further intimidating would-be business partners from engaging in permitted trade with Iran.

Leading authorities within industries impacted by the sanctions are, to say the least, sceptical of this new pledge, labeling the Obama administration’s past handling of humanitarian trade a “disaster”.

Ultimately, talk of humanitarian exemptions misses the broader point about the underlying logic of Western sanctions policies against the developing world over the past half-century. As in other cases (eg Iraq, Cuba, Gaza), the inconvenient truth of President Obama’s sanctions policy is that its effectiveness is measured directly by the level of economic suffering inflicted on the civilian population – suffering that invariably extends to the health sector his administration purportedly spares.

To take just one obvious example, rising unemployment inevitably reduces access to healthcare in a country largely reliant on employer-based health insurance, with newly uninsured Iranians among those forced into a now-thriving black market to obtain medicines and other basic care.

The recent interim deal will do little to alleviate these underlying causes of the country’s humanitarian crisis. For all the bipartisan hysteria on Capitol Hill about the easing of the sanctions, the “vast bulk” of the sanctions regime against Iran still remains in place, with the total relief over the six months of the interim deal pegged at $7bn, or just 1 percent of Iran’s GDP.

In the coming months, the Obama administration and European authorities must be held accountable for implementing their promise to ease trade in humanitarian items, especially by US media that has thus far rendered the Iranian people all but invisible in its reporting on the sanctions.

However, absent a rollback of the sanctions’ most draconian provisions, promises of humanitarian relief within a policy of collective punishment designed solely to cripple their nation’s economy are, for average Iranians, empty and self-serving gestures.

Sammy Almashat, MD, MPH is a Preventive Medicine Physician and staff researcher at Public Citizen’s Health Research Group in Washington, DC.

Maziar Shirazi, MD, is a Family Medicine Physician based in Philadelphia, PA.